Clinical competences of nursing assistants : a strategy for people management

Objective: to identify the clinical competences of nursing assistants in a hospital organization and to understand how professional acquired these competences. Method: an exploratory study of a qualitative approach, performed at a private hospital in southern Brazil, through a semi-structured interview, in May and June 2013 with 20 nursing assistants. Results: the nursing assistants who worked longer in the same work unit had a higher list of clinical competences. The acquisition of clinical competences occurred through interaction with other professionals; in daily nursing practice; in previous experiences and in formal learning. Final considerations: the identifi cation of clinical competences and the way nursing assistants acquire these competences can be important resources for managing people, which can be used by nurse managers to better allocate these professionals and provide the opportunity for their professional development.


INTRODUCTION
Hospital organizations have distinguished by their assistance to patients in increasingly critical health situations that require complex answers to each situation.Thus, the hospital work requires competences of professionals who find technological changes (1) , changes in the epidemiological profile, changes in the demographic patterns of the population and more demanding patients (1)(2) .
The Nursing Service is responsible for managing a large number of professionals (3)(4) , and not only to scale the needed nurses has been a challenge, but also to distribute them.The definition of the competences required for the services and the potential of each nurse to develop these competences can be strategic to harmonize the unit workload and the professional profile to achieve better results in assistance.
The characterization and the development of competences are a challenge for health services, especially for the nurse who manages the care provided to patients (5) .The adoption of the management model by competences may be an appropriate alternative.Managers would have a broader view of the competences, so they can compare the competences required for a position and the competences of the professional, allowing the identification of gaps or competences gaps, and develop a plan for each of them, benefiting organizations and professionals (6)(7) .In the health services, these benefits can be extended to patients, as the institutional objectives are linked to improving the quality of their services (5) .
The term "competence" is not new, and it has been shown under different conceptions (8) .As a characteristic of the human being, a competence is defined as the set of knowledge, ability, and attitudes (9) .When this competence is related to the formation of the individuals and their professional experiences, it is defined as a responsible knowing how to act, recognized by others, covering knowing how to mobilize, integrate, transfer knowledge, resources and abilities in a particular context (10) .
In this research, competence is considered a complex knowing how to act, based on the mobilization and combination of knowledge, abilities, attitudes, and external resources, properly applied to a particular group of situations (11) .Thus, the competence is not purely formed by resources incorporated into the person, but also from external resources such as information, equipment and relational networks (12) .
Nurses working with people management have been concerned to qualify for assistance, redirecting nurses to direct care, representing the category together with the general direction for good working conditions, implementing continuing education programs and supporting the professional self-development.
Continuing education can be seen as a process driving to changes in the organization, providing opportunities for training and personal and professional development within a critical view and responsibility of the reality.For this, competence identification and development are used, encouraging self-development, co-ordination of training and development, evaluation programs and professional performance (13) , guiding for clinical competences training.
Considering that knowledge of clinical competences can be an important management instrument, it was opted to study this issue in a private hospital in southern Brazil that in 2008 redirected the nursing care through the establishment of the nursing assistant position.The new proposal favored the hiring of nurses to provide direct patient care, different from an earlier model in which the activities of these professionals were concentrated in the administrative dimension.
Thus, the hospital's proposal was to maintain the assignment of nurses at the administrative level and include nurses in the healthcare area, having as support a continuing education program.In this scenario, the research was conducted, based on the following guiding questions: What clinical competences did nursing assistants use in their daily practice?How did they acquire these competences?
Therefore, the objectives of this study were to identify the clinical competences of nursing assistants in a hospital organization and learn how these professionals acquired these competences.

METHOD
Exploratory research with a qualitative approach, performed at a private hospital in southern Brazil, with 154 beds, divided into different units: surgical, medical, adult intensive care unit (ICU), neonatal intensive care unit (NICU), pediatrics, surgery center (SC), obstetric center (OCE), maternity and emergency (EME).
The research participants were nurses who met the following inclusion criteria: being employed by the hospital and perform health care activities at the institution for at least six months, regardless of the work shift.Exclusion criteria were nurses who were on vacation, days off or sick leave during the period of data collection.Of the 36 nurses who worked at this hospital, 22 met the inclusion criteria and were invited individually by one of the researchers to participate in the survey; two nurses did not attend the previously scheduled interview, so the sample consisted of 20 nursing assistants.
To identify the clinical competences of nursing assistants, the interpretative approach of Benner was used, similar to the interpretation of a text, where the sentence cannot be analyzed using formal.Consideraciones finales: la identificación de las competencias clínicas y el modo cómo los enfermeros asistenciales las adquieren pueden ser importantes recursos para la gestión de personas, que podrá ser utilizado por enfermeros gestores para mejor alocar esos profesionales y dar la oportunidad su desarrollo profesional.Palabras clave: Competencia Clínica; Enfermería; Administración de Recursos Humanos en Salud; Práctica Profesional; Desarrollo de Personas.single words, but as part of a context.The interpretive approach is based on the particular context of the situation involving the right time to act.In his theoretical reference, Benner had 31 competences grouped into seven areas: the help function, teaching and training, diagnostic and monitoring, effective management of situations of fast change, administration and monitoring of the schemes and therapeutic interventions, as well as monitoring and quality assurance of practices in health and organizational competences (14) .
Benner qualified nurses in five competence levels: beginner, advanced beginner, competent, proficient and expert.The beginner does not have experience of situations that will face and their actions are based on measurable elements.The advanced beginner is guided by the rules and has difficulty in mastering the situation in a broader perspective.The competent can distinguish between relevant and irrelevant aspects of a clinical situation, making their actions more efficient.The proficient grasps aspects of a situation that deserve more attention and focuses straight on the issue.The expert has the ability to anticipate problems and anticipate actions with extensive assertiveness; he is recognized by his peers and patients (14) .
In data collection, the participant was asked to tell one or two stories from clinical care to a patient and how was his behavior.The senses of reports of the nursing assistants were analyzed by extracting the areas of nursing practice and, from these, the competences according to the adopted reference.
To learn how nurses acquired the competences, the following question was made: could you tell me how did you acquire clinical competences to work in this hospital unit?A vignette with the concept of competence was presented to the nurses.Data analysis was performed using content analysis, developed in three stages: pre-analysis, material exploration, data processing and interpretation (15) .The interviews were conducted in May and June 2013, in a room reserved at the workplace of participants with previously scheduled time, and were recorded in an audio device, in line with the participants and later transcribed in full.
The research was approved by the Ethics and Research Committee on Human Beings of the Federal University of Paraná.Participants were informed about the research objectives and signed the Informed Consent Form (TCLE).The word nurse followed by a letter of the alphabet was used to protect the anonymity of the participants.
The results are presented in two steps.The first step brings the clinical competences of nursing assistants, organized according to Box 1, and the second step shows how the nurses acquired these competences.

First step: Clinical competences of nursing assistants
The clinical competences identified according to Benner´s references (14) were distributed according to the time of performance of nursing assistants in their profession (Box 1) because it is believed that the clinical competences are developed from the first contact between professionals and nursing.Thus, it was considered the length of experience in the profession and not only in the institution.The number of clinical reports of each nursing assistant and the current unit of work of nurses are also presented in Box 1.

Second step: The acquisition of clinical competences by nursing assistants
From the speeches of the nursing assistants, four categories emerged: interaction with other professionals; the daily life of nursing practice; previous experiences; formal learning.

Category 1: Interaction with other professionals
The data revealed that the interaction of nursing assistants with other professionals of the health care team was a practice that favored the acquisition of clinical competences.Among these professionals of the health team, the unit´s nurse coordinator, the nursing technicians, and doctors were mentioned by the nursing assistants:  It was found that the performance of the specialization course contributes to the acquisition of specific competences, directed to a particular area of nursing.

DISCUSSION
According to Box 1, beginners of clinical nursing practice, who worked from 6 months to 1 year in the profession, did not present a list of clinical competences, because only one competence was identified in their reports, which can be explained by the short time in nursing practice.
Among the five levels of competences proposed by Benner: novice, beginner, advanced beginner, competent, proficient and expert (14) , it is believed that these professionals occupy the first level of competences.For the theory (14) , novices are those who have no experience of situations they will face and be based on measurable elements, independent of context, to guide their actions and, therefore, need supervision from more experienced nurses.
Even with little time of work in nursing, there are nursing assistants responsible for more than one hospital unit, or in highly complex care units such as ICU.However, the nurses who work in intensive care, as well as an adequate qualification, they need mobilizing specific competences, when carrying out their activities, enabling them to develop their functions effectively, combining technical and scientific knowledge, technological devices domain, humanization, and individualization of care (16) .
From this perspective, it is important that the management of people worries in adequate nurses to their roles, to achieve measurable results for the effectiveness and efficiency.This adaptation begins at the moment of capture of human resources since to carry out an appropriate staff recruitment process, the profile and competences are outlined in each unit requiring this professional (5) .
When the nursing assistants operate 1-2 years in nursing, clinical competences begin to emerge.However, there is heterogeneity between them because, among the five competences, it was found that only three are different, linking to the fact that these nurses have not faced enough clinical situations to diversify their role of clinical competences.
To promote the development of competences of these professionals, it is important to keep them in their work units since the competences are built as the individual faces situations (17) .Also, the progressive domain of competence is distributed in time and environments that implement programs that address their development, from a growing logic of complexity and may or may not occur in formal education contexts (11) .Among the strategies for keep qualified nurses, there is the support for education and the allocation of appropriate human resources to meet the needs of each unit (18) .
However, few hospitals cultivate a human resources policy with to develop the potential of professionals who believe in an integrated manner, capture, and staff retention.Most hospitals do not concern to establish an effective policy for enhancement of internal human resources, believing that the professional can be replaced easily and also attributing excessive value to technology for improving the quality of nursing care (13) .
Similar to nursing assistants who work from 6 months to 1 year in nursing, it was found that those who worked 1-2 years in the profession were also working with high technological density and complexity care units such as ICU and NICU.However, ICU patients are considered critical and highly complex, enhancing the need for continued development of competences in professionals working in this unit, to harmonize the service between high technology and nursing care (1) , demonstrating the need for strategies that can contribute to diversification of clinical competences of nurses working in these areas.
Most of the reports from nursing assistants who work 2-3 years in the profession, clinical competences were identified.It can be seen that only the competences "to help the patients integrate the disease implications and recovery in their lifestyle" had already appeared in this study; the other emerged for the first time and represent greater flexibility, both in detecting the problems of individuals and the attitudes of nursing assistants.
Nurses who work 2-3 years with specific patients can achieve the appropriate level of competence.At this level, the nurse can discern between relevant and irrelevant aspects of a clinical situation, with planned and more efficient actions (14) .A study carried out by competent nurses working in medical-surgical unit showed that they were able to anticipate and solve routine clinical problems, and as they became more confident in their practice, the problems were solved more easily (19) .
Regarding nursing assistants E, L, and J, who worked 3-4 years in nursing, it was not possible to identify clinical competences in all clinical reports.It is believed that this fact reflects the internal mobility of these professionals since they all were relocated from work unit, even after being working for more than one year in this unit.
Nurses working in units with high turnover rate do not reach expertise because they did not undergo circumstances they could acquire the necessary experience for their progress (14) .A study conducted in a hospital in Ecuador pointed out that the retention of nurses is a major concern because the increase in turnover can affect the quality of care (20) .
In all clinical reports of the nursing assistants who worked 5-6 years in nursing, clinical competences were identified.The same happened with the nursing assistant N, who has operated from 7 to 8 years in nursing.It is noteworthy that the nurse Q has not changed actuation unit since his admission to Rev Bras Enferm [Internet].2016 jan-feb;69(1):130-7.
the hospital in EME, the nurse N had worked in the ICU unit where is currently working.
Nurses working with the same patients acquire experience through frequent exposure to situations, and the practice is transformed by the experience, and the experience is the vehicle for professional development (21) , which reinforces the importance to maintain and encourage nurses to remain in their work units.
Not all nurses working 6-7 years in nursing presented clinical reports in which it was possible to identify the competences.It is seen that this fact can be associated with the careers of those nursing assistants.One of them was working as a nursing assistant as a "substitute", for nurses on vacation or days off and he did not have a fixed unit to work.It is believed that in each unit changing, nurses need to face new clinical situations that require knowledge, competences and attitudes geared to each of them.The other nursing assistants, although working 6-7 years in nursing, they were working only for nine months in the clinical unit at that hospital and they previously worked in more than eight different nursing areas.
Excessive mobility and turnover of nurses, linked to the youth of many work teams, are elements that determine the professional immaturity and inexperience.Thus, in a large number of teams, there are expert nurses who take the leadership role in the management of care in nursing and also in the training processes and continuous improvement (22) .
A single nurse has been operating for over ten years in nursing.However, it was not possible to identify any clinical competence in his clinical reports, revealing that only the time in the profession is not synonymous with experience.The experience of a professional does not mean the time a person exercised an activity but refers to an active process of changing theories and ideas linked to a nearby reality (14) .
Regarding the acquisition of clinical competences by nursing assistants, it was found that one of the ways to gain these competences was through interaction with other health team members.This is feasible since the construction of new competences requires interaction between individuals and groups (23) .Also, the performance of quality nursing service is dependent on a learning and knowledge sharing culture in competences for patient care, among other things (24) .
The nurse as the group's coordinator should provide the space for integration of thinking, feeling and acting.He should encourage the overcoming of thought-explanatory, knowing through the contact, the sensations of discovery and learning with each other (25) .Those with more experience should also support new nurses in the pursuit of clinical knowledge; otherwise, they will be unable to overcome the challenges not fully experience to achieve clinical expertise (14) .
Usually, political-bureaucratic and economic conditions of the organizations do not allow recent graduates to be accompanied by an experienced professional.Moreover, health institutions do not offer a systematic program of education for these professionals.Thus, the theory is talking by itself, and most of the time, the practice is developed based on the "hit and error" (26) .
On the other hand, some nurses who are starting in the profession, feeling vulnerable because of the lack of ability to perform certain procedures, seek support from the nursing technicians and other team members (27) .It is possible to learn from individuals familiar with the actual contexts of practice.However, there is still an immense appreciation of academic knowledge and little regard for the knowledge gained through practical action, which should be much more a social issue than scientific (28) .Other acquisition of clinical competences was through every day nursing practice.In this sense, the situation provides to turn everyday situations into learning, exploring reflexively problems of practice and considering the labor process in its intrinsic context (28) .Building competences that appear from a real need for learning in knowledge mobilization situations is possible.However, it should be accompanied by a critical reflection (8) since it is a continuous development process that includes the search and learning from professionals (5) .
After observing the clinical course of different patients, the nurse learns to expect a sequence of events, even though he never signed that expectation.This knowledge only comes with clinical practice and not with known or generalized abstractions (14) , being in the importance of clinical experience to those working directly in patient care.
Previous experiments have also been identified as an essential element in the process of acquisition of clinical competences.It is believed that the nursing assistant who lived concrete experiences, use them to drive future situations, which provides greater ease of managing unprecedented or unusual clinical situations.
Knowledge, abilities, and attitudes developed in previous situations underlie the basic competences to provide answers face to unusual and unforeseeable circumstances.Individual and collective resources are now put into action to find similarities between the previous and current experiences.External and domestic changes of professionals are mobilized to achieve a result, how to solve problems in new situations.If the competences acquired handle the unforeseen situation, another instance of learning is created (29) .
In addition to previous experience, the nursing assistants also listed formal learning as a way for the acquisition of clinical competences.The knowledge from formal learning are indispensable to the work of nurses; a good education is critical to obtaining high-level nurses, able to evaluate the most complex situations and provide consistent solutions to real problems (14) .
Managers of health institutions should also invest in a training program for human resources for health as this is characterized as a valuable instrument for developing professionals (1) .As an example, there is the continuing education, which implies the reversal of the logic of the education process, linking teaching and learning to the daily lives of organizations and social and labor practices in the real context in which they occur, significantly transforming educational strategies from practice as a source of knowledge and problems, questioning the doing itself (28) .

FINAL CONSIDERATIONS
The identification of clinical competences and the way to the nursing assistants acquire them, proved to be an important resource for people management in nursing.Knowledge of the role of clinical competences of nurses contributes to better allocating of professionals and allows the identification of gaps that, together with the way of acquisition of clinical competences, can direct the educational activities within hospitals.
It is noteworthy that it is possible to identify the clinical competences required for each care unit and allocate the nursing assistants according to their competences so that they have improved in solving clinical problems for the benefit of patients and also enable the development of professionals.It is a process that must be worked since the admission of nurses in the organization and periodically monitored to make the necessary adjustments.It must be part of the organizational goals and people management.
Regarding the acquisition of clinical competences, it was found that the learning in the context of the practice was highlighted.It allows reflecting on the trend, so the acquisition of clinical competences is associated with the practical experiences through the contribution of professionals with a higher level of clinical competences.This refers to the idea that education, within organizations, should be encouraged through case studies, debates among professionals, simulations and monitoring of inexperienced nurses by competent, proficient and experts nurses.Thus, beginners of clinical practice would have a professional reference in the institution, and the most experienced nurses would be valued at their level of competence.
It is hoped that the findings of this research instigate managers nurses to identify clinical competences of their nursing assistants and implement strategies that enable the acquisition of a larger list of competences.Also, that future nurses and nursing assistants understand that the acquisition of these competences occurs along the career and needs a continuously personal and organizational investment.
[...] I had a little knowledge; I came up with a base, but this competence was acquired by contact with the nurse coordinator, a person who has a little more experience and who can help.(Nurse O) [...] We learn a lot from older nursing techniques.(Nurse P) [...] We are studying together with the doctors; this morning they did a debate [...] with the multidisciplinary team, with the nursing team, it is where we discuss what we studied, then [...] we learn more with the doctors.(Nurse D) Category 2: The daily life of nursing practice Daily life in the profession was considered as a way of acquisition of the clinical competences by nursing assistants, which must be permeated by proactive attitudes.This competence, the ability, the vision was [...] on a daily basis.(Nurse K) I [...] took an x-ray and said to the doctor: is it pneumonia?It is not misty.Auscultation is decreased.Is it because of this? [...].I accompanied visits with doctors, I questioned, why this antibiotic?[...].(Nurse F) I learn day by day, from the things I do [...].(Nurse J) Category 3: Previous experience The experiences of the nursing assistants throughout the profession and other health facilities have been identified as one of the ways of clinical competences acquisition: [...] By the experience I acquired in other institutions, clinical practice.When I was in the emergency department, a patient arrived with no change of clinical signs; suddenly, we observed and he had a stroke, a cardiac arrest was every ten minutes [...] then you will gain experience [...].(Nurse F) It was with the experience in emergency [...].(Nurse E) 134 Rev Bras Enferm [Internet].2016 jan-feb;69(1):130-7.I think that this competence comes over time.As you gain experience [...].(Nurse C)